FORMULIR PENDAFTARAN PROGRAM SISWA BERPRESTASI (PSB)

UNIVERSITAS ISLAM INDONESIA

TAHUN AKADEMIK 2010/2011

I. 1. NAMA LENGKAP :..................................................................................

2. JENIS KELAMIN :L/P
3. AGAMA :..................................................................................
4. TEMPAT/TGL/., LAHIR :..................................................................................
5. KAB./KODYA :..................................................................................
6. ALAMAT SURAT MENYURAT :..................................................................................
...................................................................................
KODE POS :.................................................................
NO. TELP/HP. :............................................................

II. 1. NAMA ORANG TUA :..................................................................................

2. PEKERJAAN :..................................................................................
3. ALAMAT :..................................................................................
4. KAB./KODYA :..................................................................................
...................................................................................
KODE POS :.................................................................
NO. TELP/HP. :............................................................

III. 1. ASAL SMA/SMK/MAN :..................................................................................

2. ALAMAT SEKOLAH :..................................................................................
3. KAB./KODYA :..................................................................................
4. STATUS SMA/SMK/MAN : 1. Negeri
2. Swasta dengan status disamakan
5. BAHASA PENGANTAR di KELAS : 1. Bahasa Indonesia
2. Bahasa Inggris
6. NILAI :

No. Kelas Semester Nilai Rata-Rata

1. Dua III
IV
2. Tiga IV
V

IV. PILIHAN FAKULTAS/JURUSAN/PRODI YANG DI INGINKAN

1 .............................................. 4 ..............................................
2 .............................................. 5 ..............................................
3 .............................................. 6 ..............................................

v. PRESTASI YANG PERNAH DIPEROLEH (LAMPIRKAN SERTIFIKAT)

1 ..............................................
2 ..............................................
3 ..............................................
......................................2010

(............................................)

Nama Terang
NB: Formulir ini dapat digandakan
Cara Pendaftaran : Pendaftaran dilakukan secara kolektif oleh Kepala Sekolah SMA/SMK/MAN dan sederajat